- Email: [email protected]
Development of a Health Screening Clinic
European Psychiatry 25 (2010) S29-S33
Development of a Health Screening Clinic H.L. Millar Carseview Centre, 4 Tom McDonald Avenue, Dundee, DD2 1NH, United-Kingdom
Abstract Medical morbidity and mortality levels remain elevated in people with schizophrenia compared with the general population. Despite the increasing recognition of an excess of physical health problems in this population, health screening remains limited. Medical risk in this population can be related to a variety of sources. The disease process itself as well as poor diet and sedentary lifestyle contribute to the overall physical health problems. In addition antipsychotic medication can contribute to the risk of cardiovascular and metabolic problems. The Dundee Health Screening Clinic was developed to address the needs of this population by monitoring physical health and providing follow-up to ensure that patients received the necessary care. The Clinic demonstrates how a coordinated approach can be used to take simple steps to improve the overall well-being of these patients. It was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. Simple clinical measurements and tests were conducted in the Clinic and patients clearly demonstrated on a satisfaction questionnaire that they considered the health checks important. This Clinic is an example of how a holistic approach can impact on both the physical and mental well-being of patients and offer them improved care and therefore a better quality of life. Keywords: Schizophrenia; Health screening; Physical health.
1. Introduction
2. Background
There is an increasing awareness that people with severe mental illness, particularly schizophrenia, have a higher risk of developing cardiovascular and metabolic problems than the general population [4]. There are a variety of sources of risk factors, many of which are modifiable [5]. It is important that these risk factors are identified early through health screening so that people who are vulnerable engage in healthy lifestyle programmes to prevent or reduce metabolic problems, including diabetes mellitus, and their consequences such as cardiovascular disease (CVD). In addition it is clear that certain second-generation (atypical) antipsychotic medications can exacerbate the risks of developing metabolic syndrome and CVD [14,21]. It is therefore essential that those with severe and enduring mental health problems who are prescribed such medication receive regular health screening to ensure the early detection of metabolic adverse effects and referral to an appropriate health care specialist [15].
Increased physical co-morbidity and excess mortality are associated with severe mental illness, especially schizophrenia [20]. It is now established that people with schizophrenia may experience up to a 20% shorter lifespan than the general population and that physical co-morbidity accounts for 60% of premature deaths not related to suicide [12]. Individuals with schizophrenia have increased rates of coronary heart disease, diabetes, hypertension, stroke and emphysema, which often go unnoticed by health care professionals [15]. High levels of malignant neoplasm have also been reported [11] and human immunodeficiency virus (HIV)/hepatitis prevalence is greater than in the general population [7]. People with schizophrenia are less likely to raise a medical complaint, and as a result illnesses can go unrecognised and untreated for many years. In addition there is a recognised reluctance by non-psychiatrists to treat people with severe mental health problems [9]. Due to their mental health problem, people may also fail to recognise the early signs of physical ill health or may choose to avoid contact with health services [6]. Factors associated with the mental health problem combined with lifestyle ‘choices’ (Table 1) can predispose
Correspondence. Tel.: +44 (0) 1382 878796. E-mail address: [email protected] © 2010 Elsevier Masson SAS. All rights reserved.
S30
H.L. Millar / European Psychiatry 25 (2010) S29-S33
Table 1 Sources of medical risk in major mental disorders[15]. Related to disease
Related to system of care
• Symptoms • Genetic link with diabetes?
• Fragmentation • Poor access
Related to health behaviours
Related to treatment
• Alcohol and substance abuse • HIV and hepatitis C • Smoking • Inactivity • Poor nutrition
• Weight gain • Neurological effects • Diabetes • Hyperlipidaemia • Cardiovascular • Hyperprolactinaemia
patients with psychiatric illness to poor physical health and disease. Compared with the normal population, individuals with schizophrenia are less likely to engage in exercise and more often eat diets high in fat and low in fibre [5,8,16]. In addition they are more likely to smoke and to have high rates of alcohol and illicit drug misuse [5,9,16]. Schizophrenia itself, independent of lifestyle habits or medication prescribed, has been considered as a potential risk factor for the development of metabolic disorders such as diabetes [10,22]. In addition to schizophrenia and the related lifestyle issues described above, antipsychotic medication can also impact on physical well-being. Although the second generation antipsychotics are associated with less in the way of movement disorders they appear to carry increased risks of weight gain, dyslipidaemia and Type 2 diabetes [18,19]. Therefore, despite the substantial improvements in pharmacotherapy, strategies for monitoring and maintaining physical health are required in order to ensure the physical well-being of these patients, enhance their adherence to therapy and achieve optimal outcomes. Despite the above evidence and growing awareness, health screening for the severe and enduring mentally ill remains inconsistent across the UK and Europe. 3. Development of a Health Screening Clinic With the growing awareness of co-morbid physical health problems in the severe and enduring mental illness population, a Health Screening Clinic was set up in Dundee, Scotland to address this issue, starting in 2002. The development took place in three phases as described below. 3.1.
Phase I
The Clinic was set up in the community setting with a multidisciplinary team drawn from the Community Mental Health Team and day hospital staff. The Clinic team included nursing staff as well as occupational therapists and physio-
therapists. A rota was incorporated to enable the Health Screening Clinic to run once a week. The Clinic was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. A pilot study was conducted to assess the feasibility of health screening and to define best practice. The pilot enrolled 152 community-based patients over a period of 18 months with a female to male ratio of 1:2 and an age range of 26 to 68 years. The study population included mainly schizophrenia (72%); the remainder were schizoaffective disorder, bipolar disorder and recurrent depression. All of the patients were prescribed antipsychotic medication. The recognised modifiable risk factors were identified, including smoking, obesity, hypertension and dyslipidaemia and glucose intolerance. The results of the pilot study (Fig. 1) confirmed studies already conducted, demonstrating that this population carried a heavy burden of modifiable risk factors and co-morbid physical health problems. 3.2.
Phase II
The pilot study clearly demonstrated that this population required systematic health checks in order to diagnose co-morbid physical problems as early as possible and to seek interventions as required from primary care doctors or specialists. Phase II included an audit of metabolic syndrome according to the new international definition [1] (Table 2) in order to quantify the physical health problems. A database was set up to record the measurements completed within the Clinic. Results were collected and appropriate follow-up was organised through primary care or specialist services. In order to provide seamless access to care, the health checks were extended to include both inpatients and community patients during this phase. The Clinic included three main types of clinical investigations and interventions: physical examination, electrocardiogram (ECG), and blood screening; rating scales with medical/drug histories; and
H.L. Millar / European Psychiatry 25 (2010) S29-S33
S31
Fig. 1. Modifiable risk factors identified in Phase I of the Health Screening Clinic. a Previous history of Diabetes Mellitus/Impaired Glucose in population (including those receiving insulin or oral antidiabetic agents).
diet and lifestyle advice. Further lifestyle interventions such as individual menu planning and a range of exercise classes were available. Liaison included interface with diabetology, cardiology and dietetics to increase awareness of the development of the Health Screening Clinic and of the potential for referrals for advice and management. Nursing staff were trained in blood letting, measuring blood pressure (BP) and waist circumference (WC) and completing ECGs. In addition staff attended educational sessions on the Drug Attitude Inventory [13] and the Side-Effects Scale/Checklist for Antipsychotic Medication (SESCAM) [3] to ensure confidence in completing rating scales. Equipment was reviewed to check that ECGs and BP monitors were modern and accurate.
Of the first 100 patients audited, 33% were identified with metabolic syndrome, reflecting the increased burden of physical co-morbidity, including cardiovascular and metabolic problems, in this population. Following this phase, 100 user satisfaction questionnaires were distributed, with 46% returned by patients who had attended the Clinic. Of these, 99% agreed that the Health Screening Clinic checks were important and stated that they would recommend patients to attend; 65% stated that they had changed their lifestyle as a result of the Clinic. From a comment section on the questionnaire it was clear that patients wanted more information and advice about their physical health and check-ups.
Table 2 The international definition of the metabolic syndrome from the International Diabetes Federation (2005) [1]. Metabolic syndrome is defined by central obesity (by waist circumference) plus any two of the other four criteria: Waist circumference
Men ≥ 94 cm (37 inches)a Women ≥ 80 cm (31.5 inches)a
Blood pressure
≥130/85 mmHgb
Triglycerides
>150 mg/dL (>1.7 mmol/L)b
HDL-cholesterol
<40 mg/dL (<1.03 mmol/L) in menb <50 mg/dL (<1.29 mmol/L) in womenb
Fasting plasma glucose a
≥100 mg/dL (≥5.6 mmol/L)c
Adjusted for ethnicity Or on treatment c Or known type 2 diabetes. Oral glucose tolerance test is strongly recommended but is not necessary to define the presence of the syndrome. b
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H.L. Millar / European Psychiatry 25 (2010) S29-S33
Table 3 UK recommendations for initial evaluation and ongoing monitoring of patients with schizophrenia [2]. Initial visit Personal/family history
8 wk*
12 wk
6 mo
√
BMI (height/weight )
√
Blood pressure
√
Fasting plasma glucose
√
Fasting lipid profile
√
2
4 wk*
Annually thereafter √
√
(√)
√
(√)
√
√
√
√
√
√ √
*Assessment at these times is desirable but not always practicable. Some assessments may not be practicable at the initial visit. Clinical judgement should be used to decide which evaluations can be carried out later. Random glucose levels are acceptable if fasting measurements are impracticable. Measurement of height will be required only at the initial visit.
3.3. The Future of the Health Screening Clinic Programme (Phase III) The future plan (Phase III) is to develop individualised lifestyle programmes for high-risk individuals identified with metabolic syndrome. These programmes, which are over and above the present lifestyle programme offered to all engaged at the Clinic, will include specialist dietary advice and a specific quantifiable exercise regimen monitored and supervised by a key worker along with a dietician and physiotherapist. The aim of the programme is to shift metabolic/ cardiovascular parameters into the normal range in order to improve physical health, life expectancy and the overall quality of life for this population.
What is now clear is that early intervention is the key to both physical and mental well-being in patients with schizophrenia. A holistic approach is required to provide easily accessible physical health screening with basic lifestyle programmes and appropriate medical follow up when required. It is only by providing people with schizophrenia with an opportunity to receive equal access to health care that we will hopefully start to improve life expectancy and quality of life for this population. 5. Conflicts of interest H. L. Millar: Speaker/Advisor: Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka and Merck Pharmaceuticals.
4. The way forward References Despite the development of guidelines and recommendations, the physical health screening of the severe mentally ill population remains inadequate. Psychiatric and primary care services do not appear to be implementing accessible appropriate health screening within current systems. What is clear is that there is no specific best model, but national guidance should be adapted to meet local needs, taking into account available resources and current service provision. Recently within the UK, a group of experts met to address metabolic and cardiovascular risk in people with schizophrenia. This meeting resulted in a Consensus Statement providing clinicians with a framework for assessment, monitoring and managing metabolic and cardiovascular problems in this population (Table 3) [2]. The Consensus Statement represents a guide for good practice in keeping with recent UK Department of Health guidelines [23] and National Institute for Health and Clinical Excellence (NICE) recommendations [17].
[1] [2]
[3]
[4] [5] [6] [7]
[8]
[9]
Alberti KG, Zimmet P, Shaw J. The metabolic syndrome-a new worldwide definition. Lancet 2005;366:1059-62. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gadsby R, Heald A, et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007;21:357-73. Bennett J, Done J, Hunt B. Assessing the side-effects of antipsychotic drugs: a survey of CPN practice. J Psychiatr Ment Health Nurs 1995;2:177-82. Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997;171:502-8. Brown S, Birtwistle J, Roe L, Thompson C. The unhealthy lifestyle of people with schizophrenia. Psychol Med 1999;29:697-701. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000;177:212-7. Davidson S, Judd F, Jolley D, Hocking B, Thompson S, Hyland B. Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill. Aust N Z J Psychiatry 2001;35:203-9. Druss BE, Bradford WD, Rosenheck RA, Radford MJ, Krumholz HM. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001;58:572. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psychiatry 1999;60(Suppl. 21):10-5.
H.L. Millar / European Psychiatry 25 (2010) S29-S33
[10] Gough SC, O’Donovan MC. Clustering of metabolic comorbidity in schizophrenia: a genetic contribution? J Psychopharmacol 2005;19 (6 Suppl.):47-55. [11] Halbreich U, Shen J, Panaro V. Are chronic psychiatric patients at increased risk for developing breast cancer? Am J Psychiatry 1996;153:559-60. [12] Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005;150:1115-21. [13] Hogan TP, Awad AG, Eastwood R. A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychol Med 1983;13:177-83. [14] Koro CE, Fedder DO, L’Italien GJ, Weiss S, Magder LS, Kreyenbuhl J, et al. An assessment of the independent effects of olanzapine and risperidone exposure on the risk of hyperlipidemia in schizophrenic patients. Arch Gen Psychiatry 2002;59:1021-6. [15] Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003;178:S67-S70. [16] McCreadie RG. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry 2003;183:534-9.
S33
[17] National Collaborating Centre for Chronic Conditions. Clinical Guidelines for type 2 diabetes mellitus: management of blood glucose. London: Royal College of Physicians; 2008. [18] Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005;19(Suppl. 1):1-93. [19] Newcomer JW. Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry 2007;68(Suppl. 1):20-7. [20] Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry 1991;36:239-45. [21] Paton C, Esop R, Young C, Taylor D. Obesity, dyslipidaemias and smoking in an inpatient population treated with antipsychotic drugs. Acta Psychiatr Scand 2004;110:299-305. [22] Thakore JH, Mann JN, Vlahos I, Martin A, Reznek R. Increased visceral fat distribution in drug-naive and drug-free patients with schizophrenia. Int J Obes Relat Metab Disord 2002;26:137-41. [23] UK Department of Health. Choosing Health : Support the physical health of people with severe mental illness, Commissioning framework; 2006.
Development of a Health Screening Clinic H.L. Millar Carseview Centre, 4 Tom McDonald Avenue, Dundee, DD2 1NH, United-Kingdom
Abstract Medical morbidity and mortality levels remain elevated in people with schizophrenia compared with the general population. Despite the increasing recognition of an excess of physical health problems in this population, health screening remains limited. Medical risk in this population can be related to a variety of sources. The disease process itself as well as poor diet and sedentary lifestyle contribute to the overall physical health problems. In addition antipsychotic medication can contribute to the risk of cardiovascular and metabolic problems. The Dundee Health Screening Clinic was developed to address the needs of this population by monitoring physical health and providing follow-up to ensure that patients received the necessary care. The Clinic demonstrates how a coordinated approach can be used to take simple steps to improve the overall well-being of these patients. It was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. Simple clinical measurements and tests were conducted in the Clinic and patients clearly demonstrated on a satisfaction questionnaire that they considered the health checks important. This Clinic is an example of how a holistic approach can impact on both the physical and mental well-being of patients and offer them improved care and therefore a better quality of life. Keywords: Schizophrenia; Health screening; Physical health.
1. Introduction
2. Background
There is an increasing awareness that people with severe mental illness, particularly schizophrenia, have a higher risk of developing cardiovascular and metabolic problems than the general population [4]. There are a variety of sources of risk factors, many of which are modifiable [5]. It is important that these risk factors are identified early through health screening so that people who are vulnerable engage in healthy lifestyle programmes to prevent or reduce metabolic problems, including diabetes mellitus, and their consequences such as cardiovascular disease (CVD). In addition it is clear that certain second-generation (atypical) antipsychotic medications can exacerbate the risks of developing metabolic syndrome and CVD [14,21]. It is therefore essential that those with severe and enduring mental health problems who are prescribed such medication receive regular health screening to ensure the early detection of metabolic adverse effects and referral to an appropriate health care specialist [15].
Increased physical co-morbidity and excess mortality are associated with severe mental illness, especially schizophrenia [20]. It is now established that people with schizophrenia may experience up to a 20% shorter lifespan than the general population and that physical co-morbidity accounts for 60% of premature deaths not related to suicide [12]. Individuals with schizophrenia have increased rates of coronary heart disease, diabetes, hypertension, stroke and emphysema, which often go unnoticed by health care professionals [15]. High levels of malignant neoplasm have also been reported [11] and human immunodeficiency virus (HIV)/hepatitis prevalence is greater than in the general population [7]. People with schizophrenia are less likely to raise a medical complaint, and as a result illnesses can go unrecognised and untreated for many years. In addition there is a recognised reluctance by non-psychiatrists to treat people with severe mental health problems [9]. Due to their mental health problem, people may also fail to recognise the early signs of physical ill health or may choose to avoid contact with health services [6]. Factors associated with the mental health problem combined with lifestyle ‘choices’ (Table 1) can predispose
Correspondence. Tel.: +44 (0) 1382 878796. E-mail address: [email protected] © 2010 Elsevier Masson SAS. All rights reserved.
S30
H.L. Millar / European Psychiatry 25 (2010) S29-S33
Table 1 Sources of medical risk in major mental disorders[15]. Related to disease
Related to system of care
• Symptoms • Genetic link with diabetes?
• Fragmentation • Poor access
Related to health behaviours
Related to treatment
• Alcohol and substance abuse • HIV and hepatitis C • Smoking • Inactivity • Poor nutrition
• Weight gain • Neurological effects • Diabetes • Hyperlipidaemia • Cardiovascular • Hyperprolactinaemia
patients with psychiatric illness to poor physical health and disease. Compared with the normal population, individuals with schizophrenia are less likely to engage in exercise and more often eat diets high in fat and low in fibre [5,8,16]. In addition they are more likely to smoke and to have high rates of alcohol and illicit drug misuse [5,9,16]. Schizophrenia itself, independent of lifestyle habits or medication prescribed, has been considered as a potential risk factor for the development of metabolic disorders such as diabetes [10,22]. In addition to schizophrenia and the related lifestyle issues described above, antipsychotic medication can also impact on physical well-being. Although the second generation antipsychotics are associated with less in the way of movement disorders they appear to carry increased risks of weight gain, dyslipidaemia and Type 2 diabetes [18,19]. Therefore, despite the substantial improvements in pharmacotherapy, strategies for monitoring and maintaining physical health are required in order to ensure the physical well-being of these patients, enhance their adherence to therapy and achieve optimal outcomes. Despite the above evidence and growing awareness, health screening for the severe and enduring mentally ill remains inconsistent across the UK and Europe. 3. Development of a Health Screening Clinic With the growing awareness of co-morbid physical health problems in the severe and enduring mental illness population, a Health Screening Clinic was set up in Dundee, Scotland to address this issue, starting in 2002. The development took place in three phases as described below. 3.1.
Phase I
The Clinic was set up in the community setting with a multidisciplinary team drawn from the Community Mental Health Team and day hospital staff. The Clinic team included nursing staff as well as occupational therapists and physio-
therapists. A rota was incorporated to enable the Health Screening Clinic to run once a week. The Clinic was set up by adapting the manpower resources and procedures of the community mental health team and local resource centre, without specific additional funding. A pilot study was conducted to assess the feasibility of health screening and to define best practice. The pilot enrolled 152 community-based patients over a period of 18 months with a female to male ratio of 1:2 and an age range of 26 to 68 years. The study population included mainly schizophrenia (72%); the remainder were schizoaffective disorder, bipolar disorder and recurrent depression. All of the patients were prescribed antipsychotic medication. The recognised modifiable risk factors were identified, including smoking, obesity, hypertension and dyslipidaemia and glucose intolerance. The results of the pilot study (Fig. 1) confirmed studies already conducted, demonstrating that this population carried a heavy burden of modifiable risk factors and co-morbid physical health problems. 3.2.
Phase II
The pilot study clearly demonstrated that this population required systematic health checks in order to diagnose co-morbid physical problems as early as possible and to seek interventions as required from primary care doctors or specialists. Phase II included an audit of metabolic syndrome according to the new international definition [1] (Table 2) in order to quantify the physical health problems. A database was set up to record the measurements completed within the Clinic. Results were collected and appropriate follow-up was organised through primary care or specialist services. In order to provide seamless access to care, the health checks were extended to include both inpatients and community patients during this phase. The Clinic included three main types of clinical investigations and interventions: physical examination, electrocardiogram (ECG), and blood screening; rating scales with medical/drug histories; and
H.L. Millar / European Psychiatry 25 (2010) S29-S33
S31
Fig. 1. Modifiable risk factors identified in Phase I of the Health Screening Clinic. a Previous history of Diabetes Mellitus/Impaired Glucose in population (including those receiving insulin or oral antidiabetic agents).
diet and lifestyle advice. Further lifestyle interventions such as individual menu planning and a range of exercise classes were available. Liaison included interface with diabetology, cardiology and dietetics to increase awareness of the development of the Health Screening Clinic and of the potential for referrals for advice and management. Nursing staff were trained in blood letting, measuring blood pressure (BP) and waist circumference (WC) and completing ECGs. In addition staff attended educational sessions on the Drug Attitude Inventory [13] and the Side-Effects Scale/Checklist for Antipsychotic Medication (SESCAM) [3] to ensure confidence in completing rating scales. Equipment was reviewed to check that ECGs and BP monitors were modern and accurate.
Of the first 100 patients audited, 33% were identified with metabolic syndrome, reflecting the increased burden of physical co-morbidity, including cardiovascular and metabolic problems, in this population. Following this phase, 100 user satisfaction questionnaires were distributed, with 46% returned by patients who had attended the Clinic. Of these, 99% agreed that the Health Screening Clinic checks were important and stated that they would recommend patients to attend; 65% stated that they had changed their lifestyle as a result of the Clinic. From a comment section on the questionnaire it was clear that patients wanted more information and advice about their physical health and check-ups.
Table 2 The international definition of the metabolic syndrome from the International Diabetes Federation (2005) [1]. Metabolic syndrome is defined by central obesity (by waist circumference) plus any two of the other four criteria: Waist circumference
Men ≥ 94 cm (37 inches)a Women ≥ 80 cm (31.5 inches)a
Blood pressure
≥130/85 mmHgb
Triglycerides
>150 mg/dL (>1.7 mmol/L)b
HDL-cholesterol
<40 mg/dL (<1.03 mmol/L) in menb <50 mg/dL (<1.29 mmol/L) in womenb
Fasting plasma glucose a
≥100 mg/dL (≥5.6 mmol/L)c
Adjusted for ethnicity Or on treatment c Or known type 2 diabetes. Oral glucose tolerance test is strongly recommended but is not necessary to define the presence of the syndrome. b
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H.L. Millar / European Psychiatry 25 (2010) S29-S33
Table 3 UK recommendations for initial evaluation and ongoing monitoring of patients with schizophrenia [2]. Initial visit Personal/family history
8 wk*
12 wk
6 mo
√
BMI (height/weight )
√
Blood pressure
√
Fasting plasma glucose
√
Fasting lipid profile
√
2
4 wk*
Annually thereafter √
√
(√)
√
(√)
√
√
√
√
√
√ √
*Assessment at these times is desirable but not always practicable. Some assessments may not be practicable at the initial visit. Clinical judgement should be used to decide which evaluations can be carried out later. Random glucose levels are acceptable if fasting measurements are impracticable. Measurement of height will be required only at the initial visit.
3.3. The Future of the Health Screening Clinic Programme (Phase III) The future plan (Phase III) is to develop individualised lifestyle programmes for high-risk individuals identified with metabolic syndrome. These programmes, which are over and above the present lifestyle programme offered to all engaged at the Clinic, will include specialist dietary advice and a specific quantifiable exercise regimen monitored and supervised by a key worker along with a dietician and physiotherapist. The aim of the programme is to shift metabolic/ cardiovascular parameters into the normal range in order to improve physical health, life expectancy and the overall quality of life for this population.
What is now clear is that early intervention is the key to both physical and mental well-being in patients with schizophrenia. A holistic approach is required to provide easily accessible physical health screening with basic lifestyle programmes and appropriate medical follow up when required. It is only by providing people with schizophrenia with an opportunity to receive equal access to health care that we will hopefully start to improve life expectancy and quality of life for this population. 5. Conflicts of interest H. L. Millar: Speaker/Advisor: Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka and Merck Pharmaceuticals.
4. The way forward References Despite the development of guidelines and recommendations, the physical health screening of the severe mentally ill population remains inadequate. Psychiatric and primary care services do not appear to be implementing accessible appropriate health screening within current systems. What is clear is that there is no specific best model, but national guidance should be adapted to meet local needs, taking into account available resources and current service provision. Recently within the UK, a group of experts met to address metabolic and cardiovascular risk in people with schizophrenia. This meeting resulted in a Consensus Statement providing clinicians with a framework for assessment, monitoring and managing metabolic and cardiovascular problems in this population (Table 3) [2]. The Consensus Statement represents a guide for good practice in keeping with recent UK Department of Health guidelines [23] and National Institute for Health and Clinical Excellence (NICE) recommendations [17].
[1] [2]
[3]
[4] [5] [6] [7]
[8]
[9]
Alberti KG, Zimmet P, Shaw J. The metabolic syndrome-a new worldwide definition. Lancet 2005;366:1059-62. Barnett AH, Mackin P, Chaudhry I, Farooqi A, Gadsby R, Heald A, et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007;21:357-73. Bennett J, Done J, Hunt B. Assessing the side-effects of antipsychotic drugs: a survey of CPN practice. J Psychiatr Ment Health Nurs 1995;2:177-82. Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry 1997;171:502-8. Brown S, Birtwistle J, Roe L, Thompson C. The unhealthy lifestyle of people with schizophrenia. Psychol Med 1999;29:697-701. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000;177:212-7. Davidson S, Judd F, Jolley D, Hocking B, Thompson S, Hyland B. Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill. Aust N Z J Psychiatry 2001;35:203-9. Druss BE, Bradford WD, Rosenheck RA, Radford MJ, Krumholz HM. Quality of medical care and excess mortality in older patients with mental disorders. Arch Gen Psychiatry 2001;58:572. Goldman LS. Medical illness in patients with schizophrenia. J Clin Psychiatry 1999;60(Suppl. 21):10-5.
H.L. Millar / European Psychiatry 25 (2010) S29-S33
[10] Gough SC, O’Donovan MC. Clustering of metabolic comorbidity in schizophrenia: a genetic contribution? J Psychopharmacol 2005;19 (6 Suppl.):47-55. [11] Halbreich U, Shen J, Panaro V. Are chronic psychiatric patients at increased risk for developing breast cancer? Am J Psychiatry 1996;153:559-60. [12] Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005;150:1115-21. [13] Hogan TP, Awad AG, Eastwood R. A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychol Med 1983;13:177-83. [14] Koro CE, Fedder DO, L’Italien GJ, Weiss S, Magder LS, Kreyenbuhl J, et al. An assessment of the independent effects of olanzapine and risperidone exposure on the risk of hyperlipidemia in schizophrenic patients. Arch Gen Psychiatry 2002;59:1021-6. [15] Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003;178:S67-S70. [16] McCreadie RG. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. Br J Psychiatry 2003;183:534-9.
S33
[17] National Collaborating Centre for Chronic Conditions. Clinical Guidelines for type 2 diabetes mellitus: management of blood glucose. London: Royal College of Physicians; 2008. [18] Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005;19(Suppl. 1):1-93. [19] Newcomer JW. Metabolic considerations in the use of antipsychotic medications: a review of recent evidence. J Clin Psychiatry 2007;68(Suppl. 1):20-7. [20] Newman SC, Bland RC. Mortality in a cohort of patients with schizophrenia: a record linkage study. Can J Psychiatry 1991;36:239-45. [21] Paton C, Esop R, Young C, Taylor D. Obesity, dyslipidaemias and smoking in an inpatient population treated with antipsychotic drugs. Acta Psychiatr Scand 2004;110:299-305. [22] Thakore JH, Mann JN, Vlahos I, Martin A, Reznek R. Increased visceral fat distribution in drug-naive and drug-free patients with schizophrenia. Int J Obes Relat Metab Disord 2002;26:137-41. [23] UK Department of Health. Choosing Health : Support the physical health of people with severe mental illness, Commissioning framework; 2006.